48. Airliner Safety and Airline Pilot Suicide

June 21, 2020

[Ed. Previously published August 4, 2019.]

This will be a a discussion about the factors that allowed Andreas Lubitz, young Germanwings co-pilot, to crash an airliner into the French Alps at 700 miles per hour, killing himself and 149 others, without anyone who knew of his mental instability preventing him from continuing on active flight status.  These are some of the reasons why it could happen in Germany why its is much less likely to happen in the Unite4d States.

After 17 years of practice as a Family Physician, I worked for the decade of the 1980’s as an Occupational and Environmental physician, heading up the SFO regional medical department of a major airline.

Following World War I, when it had been discovered that about as many pilots were lost to accidents caused by their own ill health as were shot down by the enemy, the military established the position of Flight Surgeon, and gave medical officers with that designation the power to determine pilot fitness for duty, and even the power to overrule the orders of line commanders regarding flight status. By the 1980’s, several airlines had full-service medical departments dealing with employment health and injuries. Their Flight Surgeons worked closely with the FAA’s Aeromedical Certification Branch in Oklahoma City, and had primary lines of responsibility to flight safety, the employees and the airline itself.
When I was an airline’s regional flight surgeon at SFO, which included our maintenance base, we served 25,000 local employees, of which a couple of thousand were pilots.

Not every airline had a medical department, and the jobs of my staff of 20 were constantly in jeopardy during the decade of the ‘80s, when hostile takeovers were rampant and “deregulation” had struck the aviation industry, resulting in dozens of little start-up airlines with no debt or pension load. The start-ups undercut prices severely, and the established airlines struggled to cut costs in order to compete.
Management debated year after year regarding whether to shut down the company medical department and rely upon outside contractors to provide “occupational medicine” support.

As one of the first in the company to be issued an IBM personal computer in about 1983, a departure from the corporate practice of doing everything on a huge mainframe, my hobby interest in computing had led me to write a very large relational database program on my PC that tracked demographic, medical and disability data resulting from the more than 2,000 visits per months to our medical department. Before it was over I had collected data on more than 100,000 consecutive visits to the medical department. As a result, my monthly reports were able to show that while it cost about a million dollars a year to fund my regional medical department, if the company had outsourced only the federally mandated exams, less than half our workload, to outside occupational medical clinics, it would have cost twice our department’s annual budget.

Our regional facility did pre-employment exams, with drug testing, on all employees except pilots, who were hired and drug tested by a special team at the airline’s training center in Denver. We saw all work injuries and did “fitness for duty” or return-to-work determinations on all employees, including pilots. In my experience over the years, outside doctors rarely if ever had the slightest idea what the various jobs of our employees entailed. They didn’t know, for instance, that pilots were forbidden from taking any of dozens of common medications, including any sedatives, depressants, anti-depressants, anti-seizure medications, anti-histamines, etc, etc, etc. Which is why any flight crew return-to-duty order by an outside doctor had to be rechecked by my staff of two other flight surgeons, two nurse practitioners and myself. 

The FAA requires an annual or six-month physical for pilots. It is cursory, but covers certain critical things, like eye exams and an EKG. In addition to those exams, we also did a very comprehensive annual physical on our pilots,
which covered every aspect of life and health. Always including an inquiry into alcohol consumption and medications and a question about street drugs and nicotine use.

The general rule in aviation is that no pilot may resume flying if suffering from any condition which could cause “sudden or insidious incapacitation” in the cockpit.
It should be understood that the best defense against cryptic illness or drug use was the integrity of the pilot himself or herself, who was obligated by law to report any significant change in health.
It was, and is still the case that any significant adverse change in health, reported or not, automatically voids the pilot’s official federal medical certificate, and with it his or her license to fly.

In the hiring process each pilot was administered a full battery of psychological tests, administered by psychologists, and was interviewed by our full-time company MD-psychiatrist.

The company also had a very active Employee Assistance Program (EAP), and participated as a founding member, along with the Airline Pilot’s Association (ALPA) and the FAA, of the Human Intervention and Motivation Study (HIMS).
Our EAP, medical, and union reps all participated in week- long annual trainings in intervention, evaluation and monitoring of pilots with alcohol or related substance abuse, dependency or mental health problems.

We did group interventions, with employer union and family members present, upon pilots who were brought to our attention by family or fellow pilots, or who showed abnormalities in, for instance, liver function tests. 

After a 28-day inpatient program and a couple of months of successful and whole-hearted participation in a 12-step program, it was my responsibility to decide whether it was safe to return the pilot to the cockpit. Upon my recommendation to the FAA chief psychiatrist in Washington, the pilot’s license was restored and he returned to work while being monitored by my group for an additional few months. Following which he or she was questioned extensively during the annual physical. 

The HIMS program was the first of its kind and was the pattern for ones now used for physicians, and people in other jobs where public safety is key. The recovery rate for pilots during the 80’s was 96%. This past year some addiction specialists have questioned whether my assertion of that recovery rate is credible. There are few records or reports still available on-line, but those that remain confirm that it was in that range, and that number is my personal recollection regarding a program in which I was deeply involved. 

Pilots who were not detected before committing a firing offense, like showing up in the cockpit drunk, were fired, then invited to use their full medical benefits to undergo several months of treatment and AA follow-up.

Not all airlines participated in the HIMS program. Some maintained, “We don’t have any alcoholic pilots”.  Yeah. Right.

During the years I worked for the airline, three other airlines closed their medical departments and relied solely upon the exams done by FAA Aviation Medical Examiners, (AME’s), private physicians designated by the FAA to do physical exams on pilots.

My impression is that at this point in the US very few airlines have their own medical department, though they may have a “medical director’ and contract with clinic groups who by now have become as knowledgeable about FAA requirements and flight safety as we were at my airline. 

On the other hand, perhaps because of the extensive spying that was done upon citizens in East Germany and the egregious misuse of private information thus obtained, at the time of the crash of Germanwings Flight 9525m Germant had very strict laws regarding the privacy of mental health issues.  The laws were so strict that they prevented the flow of information from several mental health professionals aware of Lubitz’ suicidal nature, from ever reaching management decision-makers at Germanwings. 

In the U.S. we have a similar problem regarding the reporting of dangerous mental conditions to those who maintain the National Instant Criminal Background System (NICS), in order to prevent certain mentally ill people from obtaining firearms. According to my most recent look at the numbers, only about 46 states require reporting. Of those, many do not forward the reports from the responsible state agency to the FBI for inclusion in the NICS database. While states require hospitals and institutions to report, and may include mandatory reporting for judicial determinations of mental illness or incompetence, there is rarely a requirement for treating physicians or clinicians to report mental illness, in the way that reporting is required for obvious reasons of public safety for venereal disease or infectious diseases like measles.

In the U.S., when there is a full airline medical department, the employer has an in-house expert who can evaluate outside medical information and pass real-time judgment on fitness for duty. Privacy insulation comes from the fact that the in-house medical team passes only a disability status recommendation to management, and not any specific medical information. At the same time management is able to be absolutely sure that company physician recommendations will conform to flight safety requirements, and that an airline doctor understands precisely what they are and what is at stake. That confidence also descends from the federal government.  At my airline we were actually also designated as Senior AME’s by the FAA, as FAA Medical Sponsors in the HIMS program and as drug test Medical Review Officers (MRO) for the Department of Transportation, so we had a strong line of responsibility to the federal government and public safety, as well as one to the company. 

The Germanwings crash triggered a debate regarding the withholding of information by mental health practitioners from the company medical staff.  And Even such information as was communicated to company medical officers was not given to managers in charge of pilot assignments.  Even then, medical and aviation officials argues against relaxing the confidentiality rules.  A year after the crash, investigators recommended allowing physicians to report known dangers to authorities.  Years afterward the problem has been addressed in some countries and remains unresolved in others.


49. How Memes Change our Language – “Cowwoborate”

June 18,2020

[Previously published October 4, 2018]

OK,  now this is pretty funny.

I think it has to do with the idea of Richard Dawkins’ memes, which definition I find it difficult to keep in mind.  But in this case it is a TV meme rather than an internet one, although there is crossover in that many people obtain their news videos on various websites.

Anyhow, back to the word, used a zillion times this week in relation to the Kavanaugh confirmation hearings.  The actual word, or perhaps I should say the word up until now, has been corroborate.  From the Latin prefix: co (cor), together, and robarare, to strengthen.

Note that there are no “w”’s in the word.

There is, however, a very common and well-known Elmer Fudd speech impediment, where he refers to Bugs Bunny as “that Wascally Wabbit!”, also exploited by the scientist character in “The Big Bang Theory” called Barry Kripke.  He refers to himself as “Bawwy”, and pronounces every r as a w.

In this day and age, when to mock a disability is a mortal sin, it is hard for me  to understand how anyone can get away with making fun of a speech impediment, but there you have it.

There is, and I wish I could remember who it is, a news reporter  who has a mild form of this speech impediment, and manages a sound that is half-way between the r and the w.  I think I recall that Barbara Walters had a touch of it as well.  But this week there have also been several non-lawyer senators and others, who, even initially, used the Elmer Fudd pronunciation.

Almost everyone with legal training has learned how to pronounce corroborate properly because it is such an important idea in the law, that testimony often requires corroboration in order to become credible.  But the countervailing influence in this case is the tendency for any repeated usage to become a meme by simple mimicry.  In the case of TV news, one can hear a linguistic error, uttered by one newscaster early in the morning, spread to several others, even on other channels or in other countries, by the end of the day.

By my count, about 40% of the people using the word corroborate, after just over a week of the Christine Ford controversy, are saying “cowwoborate”.  Strangely, they morph the first two r’s into w, then leave the last r unchanged.  Proving this is clearly a meme rather than a contagious speech impediment.

Watching the news just now, I found myself yelling, “IT’S CORROBORATE!” at the images on the screen.  They didn’t care a bit.  Within a decade sixth-grade teachers will be teaching: “cowwoborate, c-o-w-w-o-b-o-r-a-t-e, cowwoborate”.

And now you will know why.



June 13, 2020

[Previously published January 13, 2020.]

Given that the number one topic this week is impeachment, I thought it would be useful to consider what the word means and how it is used in the modern world in less extraordinary circumstances.

The first step for me in understanding the idea conveyed by a word is always to look at the derivation of the word, which usually means its Latin or Greek origins.

In this case the Latin origin is from “impedicare”, to catch or entangle, which is based in turn on, “pedica”, to fetter, which is based in turn on “pes, pedis”, meaning foot.   

Unbeknownst to those who are employing impeachment at the moment, this meaning, to trip someone up, reveals what may be their basic agenda.

The thesaurus gives us these synonyms for impeachment: to challenge, question, disparage, criticize, call into question, raise doubts about, cast aspersions on.  Thinking about the actions described by those verbs, it is clear that they could be called “pre” (or ‘extra’) legal, insofar as all they require is a naked, or even a false accusation, or a mere innuendo, that may or may not provide sufficient probable cause to take to a grand jury or court to obtain an indictment.  That is to say, that impeachment, by linguistic definition alone, does not set any evidentiary or procedural standards, nor insist upon any legal protections for the accused.  Which may explain why Trump’s political enemies may have chosen to employ this process and have thus far denied him the protections of our laws, and of our highest law, the Constitution.

Yet far more common than impeachment of a president, or even another such government official, the process of challenging, questioning, disparaging, criticizing, calling into question, raising doubts about, or casting aspersions upon is used thousands of times every day in courts, when advocates attempt to discredit witnesses in order to encourage the trier of fact not to trust their testimony.  In these cases, however, there is a referee from the get-go — the judge —  to make sure the attempt to impeach the witness is done according to legal rules of fairness.  

In another example of the basic, underlying process, politicians make a profession out of impeaching the credibility of an opponent.  Again, mere accusation is enough, even innuendo, but there is no criminal sanction that applies to the impeached, only that he or she is not believed or trusted and may lose election.  Therefore there are no legal protections to protect the maligned — not even the meager protection of slander or libel sanctions because the victims are public figures.

However, whenever there is a criminal liability that may befall the impeached, he or she must first be convicted in a court of law of the crimes charged, and all of the protections due to a citizen of the United States must be applied to that process.

Until the minute the charges are filed (with the U.S. Senate or with a court of jurisdiction) the accusations are not evidence, and until the triers of fact and law consider all the admissible evidence and arrive at their verdict, the accused is legally presumed to be innocent.

As a tactical matter, it fulfills an acknowledged strategic goal of the Democrat members of congress to, as the Old English definition of “impeachment” has it, to “hinder and prevent” the Administration, by catching, entangling and fettering its feet, tripping it up; breaking its rhythm, breaking its stride.  This evening on the news, a video shows Speaker Pelosi responding to the question of what possible benefit or satisfaction was to be gained by bringing Articles of Impeachment to the senate that have disregarded so many rules of evidence and process that they are bound to be dismissed out of hand, perhaps even in a pre-trial motion to dismiss.  After fumbling and sputtering, her mouth formed itself into a sanctimonious pout as she uttered the final truth:  “Because then he will have been impeached, forever!”

This is true because no matter what happens, whether a summary dismissal or a long trial that completely exonerates President Trump, that will never remove the indelible stain upon his name, that as President, he was impeached.  On one American in a hundred understands that an impeachment is only an accusation.  Even fewer care.  For Trump it will remain a deep wound to his narcissism, never healing.  As Speaker Pelosi said, FOREVER.

Once the Articles of Impeachment reach the Senate, the tactic fails, because none of the so-called “evidence” elicited by the House thus far will meet the standard of proof required in a trial.  The presiding judge will be the Chief Justice, not as easily bamboozled as the public and the press. 

It is not unlikely that upon reading the Articles, the Senate will pass a directed verdict to dismiss, on the basis that the evidence to impeach was inadequate (anonymous sources, hearsay) in the first place.  This will, of course, engender an eruption of political theater, a melodramatic calamity in several acts.

What you will see then is the Democrat house immediately returning to impeachment on the basis of “new” innuendo.  Because even baseless charges entangle the feet of the accused and distract him or her from the business at hand. 


51. The Abuse of Young Doctors

June 10, 2020

[Previously published July 15, 2019]

For the better part of a century at least, it had been the usual practice to work graduate doctors undergoing specialty training  continuously for three to five years on a duty-cycle typified by 36-hours on, 12-hours off, and every other weekend on duty.

In a recent article in the online medical  magazine, Medscape, a study was reported that showed that capping the work hours of medical residents at 80 per week and 30 in any single shift in 2003, had not resulted in any increase in hospital mortality, readmissions or cost of health care for hospital patients.

From my perspective at 84, and retired for  almost 20 years from a three-phase practice — family practice, board certified 17 years; Occupational and Environmental medicine for 11; then a psych residency and ten years of state hospital forensic psychiatry, I am inclined to view what has been the standard model for residency training as a cycle of (inner) child abuse, perpetuated by those who were themselves abused.

Following a year of “rotating internship” and the first of three years of an orthopedic residency I was just beginning my second orthopedic year with a rotation at a San Francisco hospital less than five minutes door-to-door from my home hospital, where my wife and three kids were living in a hospital-provided apartment. In addition to the apartment my pay was $3,000 per year.

In the first week of the rotation another ortho resident, who lived across the city, had been reluctant to come in to the hospital at 3 am for some relatively trivial problem, so the duty staff orthopedist made the rule that residents would remain in the hospital whenever on call.  No matter that the rotation hospital was smallish and calls were few and far between.

However, this meant that the next time I was on weekend call, beginning at 6 pm on Friday, I would not see my family from Friday morning to Monday evening after work.  Call was every other weekend.

The ortho Chief at that hospital was out of town.  The orthopedist who made the rule was unyielding.  Two weeks later my wife called on Sunday to tell me that she was putting the kids in the car and leaving.

Instead, I called the Chief of the residency and resigned on the spot, thinking I was “finished in this town” for doing so.  Instead, on Monday morning, my Chief recommended me for a job in a local group practice, saying that when he was young he had faced the same choice, and that he had made the opposite choice, which he later came to believe was the wrong one, due to the resulting estrangement from his family.

A few years later that brilliant orthopedic surgeon, though I know nothing more of the details, sat down against the trunk of a eucalyptus in the park at Presidio San Francisco and shot himself to death. 

I believe very strongly in the value of continuity of care and good medical training.  I do NOT believe that we need to keep young doctors on duty constantly in order to achieve it to a sufficient degree.

I believe that if more experience is needed to teach a skill, then we might keep people in training longer WITH REASONABLE AND LIVABLE PAY AND ACCOMMODATIONS in order for them to acquire it.  And at the same time give them sufficient time each day to rest and recharge in the bosom of family.

To any who object that such a scheme would be unaffordable, I say that how we allocate resources is a choice a community makes.  For too long, corporate pirates and government kleptocrats have exploited the benevolence and high ethical standards of physicians  to maintain a level of excellence in medical care for which they have never been willing to pay fair value.

And physicians, upon repeatedly experiencing that no good deed goes unpunished, have sunk in to the sadness of children long betrayed and abused.  They suffer a very high burnout rate and the highest suicide rate of any employment group

I weep for my colleagues, who will not, it seems, make use of the power they possess to regain control of their profession.

There is a very interesting theme common to the arguments of those who favor residents working virtually unlimited hours.  It manifests the logical fallacy of the excluded middle:  “Either residents must work unlimited hours or they won’t learn anything and there will be no continuity of care for patients”.

This reminds me of the way individuals with Cluster B Personality disorders tend to see the world in polarized, over-simplified, all-or-nothing terms.  Looked at from a slightly different angle, denying residents, (trainee-doctors), a healthy emotional and family life also resembles the “pervasive pattern of disregard for the rights of others”.  

Seen from that perspective, the system at its worst has been flagrantly antisocial towards its victims, however willing those victims may have been.  Residents have been like the abused spouse who is pathologically unable to set a boundary with the abuser, much less leave him or her.  Like other victims of abuse, residents still believe that if THEY can just do everything right, everything will be OK.

I have recently arrived at a theory about the state of our government, which seems unable to resolve a single problem because of the incessant need of its representatives to fight with one another and for each to prove their opponents incapable of proper parenting.  I’m thinking that we have managed to elect a “critical mass”, pun intended, of Borderline Personality Disordered persons.  It doesn’t take many Borderlines to paralyze any human community or organization.

It is depressing to think that our own profession has had so little insight into the pathological origins of its flawed teaching methods that it sees no other choice but to persevere in them.

Having ended forty years of medical practice and three separate medical specialty board certifications with a final decade of training and practice of psychiatry, and having continued to read the journals for an additional 20 years in retirement, I am more than ever convinced of a lack of congruity between the way the brain learns and the organization of medical education.  Learning and memory formation not only benefit greatly from periods of rest and sleep, they utterly depend upon them.  There is reason to suspect that we have become learned doctors DESPITE some of the ways in which we have been taught.

Since it is obvious that no resident could possibly attend every patient continuously from the beginning to the end of every episode of ill health, and, because of this, perfect “continuity of care” by an individual is impossible anyway, therefore it seems to me that a need for compromises should be acknowledged, such that, say, a TEAM could insure continuity, while its individual members were able to get enough rest and sleep, and were able to be with their families in a healthy way. 

Personally, I think that for senior members to give up the systematic exploitation of younger members would  only enhance our profession.  As for scavengers like the hospitals, insurance companies and government, shame on us for having allowed them to feast on the minds and bodies of our young.

In the 1970’s, what had been called the medical care system was suddenly called the health care DELIVERY system, as though anyone could “deliver” it. Soon thereafter cheaper substitute personnel were employed to “deliver” it and physicians were devalued.

The thing that defeats physicians is that they are so ethical that they can’t figure out a way to withhold services in a group action.  In which they have also been impaired by the laws against collective action by individual practitioners.   When California Medical Association (CMA) physicians plotted out the relative value of services in order to help docs figure out what each service and procedure was worth, it was called the Relative Value System (RVS).  The federal Fair Trade Commission charged the CMA with “conspiracy in restraint of trade”.  With no funds for legal defense the CMA agreed to recall all the RVS books.   The categorization number for each service and procedure, developed for the RVS, became the basis for the Current Procedural Terminology (CPT) system, and was afterwards required to be specified for each charge to any insurance program, including Medicaid and Medicare.  One set of actual relative value charges, calculated by multiplying each service’s relative value by a modest dollar dollar conversion factor, was hijacked by the California workers’ comp system, which set that price list as the minimum charges for those services.  Then, a couple of years later, those minimum fees were set by the state to be the MAXIMUM charges a physician could bill the state system.  Thus in California, the physicians’ useful ideas were stolen by government agencies who then turned them against doctors after forbidding doctors to use them for their own benefit and convenience.

Aside from the use of force, the only power any person or group has over another, is to withhold its labor, knowledge and services.  If physicians were able to do that in concert at strategic junctures, it wouldn’t take long before they were back in charge of every aspect of medical care where medical ethics, knowledge and training are essential.  Ironically, doctors are “hoist on their own petard” of conscience and benevolence. Modified strikes could even be accomplished without withholding critical medical services to patients, though some elective services might need to be curtailed from time to time.

But organizing docs is like trying to herd cats.  The very characteristics that cause them to accept the abuse heaped upon them by the system — the need for love and approval, or the converse, the abhorrence of the slightest disapproval — will likely prevent them ever from saving their profession from ruin through thoroughly unscrupulous political and economic contamination.

There is no evidence that the abusive aspects of residency training serves any useful purpose beyond the very limited lesson that perseverance in the face of fatigue and adversity is possible.


47. Should We be Ripping Nursing Babies From Their Mothers’ Breasts !?!?!

July 11, 2018

A few days ago in an e-mail discussion group venue serving the informational interests of a Bay Area folk music club, a member posted new lyrics to an old Tom Lehrer song: the new words intending to vilify Donald Trump for enforcing immigration law in such a way that children were separated from parents who had entered the U.S. illegally. Upon crossing the border without permission, the parents had been arrested and detained in jail pending hearings in immigration court.

This provoked the submission of other verses characterizing the first parody as part of a false political narrative, cynically contrived to focus entirely on the pathos of family disruptions and to divert the public from considering the facts and circumstances actually causing the separations.

Then there followed a mini-tempest that dipped a toe briefly into the substantive issues of the aborted strategy before being pretty much shut down when it veered into the usual internet cul-de-sac: a discussion of whether these matters were “off the topic” of music-related news and events to which the e-mail group is purposed.

Just before discussion of the purely political issues ended, a member asked this question: “Can  we at least all agree, regardless of political persuasion, that separating children from their parents  is not a solution to illegal immigration?”

What follows is the response I would have made to that question were it not inappropriate for the place in which it was asked. I would not have responded directly to the person who asked it because I believe him to be a person who would be deaf to any but an affirmative answer. Whereas, if it had been asked by one I thought was actually interested in my opinion I would have responded, “Well, it depends.”

You see, I think that it is a trick question, because it eliminates several crucial preliminary questions that, when answered, define the full meaning of “illegal immigration” and establish what laws describe how they are to be handled. Those questions must be answered before one can imagine what might be a “solution” to “illegal immigration”.

For instance, if I were asked to agree that separating kids from their parents should never be a part of, or an incidental and unsought consequence of dealing with illegal behavior, then I simply could not agree.

To explain, it will help to ask some questions of my own:

Does a nation have a right to define certain acts or behavior, like homicide or rape, to be prohibited, and punishable by imprisonment or worse? (Now don’t get excited. I am not suggesting that illegal immigrants are rapists. I’m just trying to see what we agree on.)

If someone answers yes, we can proceed. If a person says nations do not have the right to define illegal acts and specify penalties, we have no further basis for discussion.

Does a sovereign entity have a right to define certain kinds of trespass, or burglary, or fraud, or breaking and entering as prohibited behaviors punishable by imprisonment?

Same question, but more specifically having to do with entering sovereign spaces posted to prohibit unauthorized entry.

Does a nation have a right to control entry by outsiders, and to define entry of immigrants or seekers of sanctuary into the country without permission or invitation as illegal, punishable by jail or deportation?

Again if answered in the negative, for instance by globalists and anarchists, there is no basis for further discussion. If yes, we can continue.

In the Unites States, does a legal jurisdiction have the right to deny due process to any person within the U.S. boundaries?

This defines another aspect of the problem. The answer is, no. Once here no one may be sent home or anywhere else without a hearing by a judge, called “due Process”. Because of the large number of cases and the small number of judges and courts, this process can take up to two years.

Does a legal jurisdiction have the right to give or deny bail, depending upon whether a defendant is a danger to others or a potential flight risk?

Unless discussants agree that judges in preliminary hearing have the right and power to deny bail in some cases, there is no basis for further discussion.

In general criminal cases, if parents, with children in tow, are arrested in the commission of a burglary and are in custody, does the jurisdiction have the right or responsibility to see to it that the children are taken care of, by relatives if possible and if not, by the jurisdiction itself?

For further discussion, all must agree that in ordinary criminal cases, which far outnumber of immigration cases, children are always taken away from parents incarcerated for any but the briefest of times, and put into homes with relatives or into the child welfare system of the county and state.

Next are some questions of fact relating to the current state of immigration law, along with the answers as I understand them.

A) Under current law, how long is the immigration service allowed to keep children detained in jail along with their parents, when the parents were caught entering illegally and may spend months in jail? Answer: 20 days.

B) When illegal immigrant detainees are released pending their immigration hearings regarding eligibility for sanctuary, what percentage fail to show up in court and remain hidden in the community? Answer: between 35% and 45%, or about 46,000 a year.

C) Can persons attempting to enter the U.S. illegally simply be stopped, turned around and told to go to a legal portal to make application for entry or sanctuary? Answer: Yes, but not after they have touched a single toe to U.S. soil, after which they are entitled an immigration hearing, via the process that is backed up for about two years. Under Bush and Obama the policy had been to “catch and release” adults with or without children, scheduling a hearing for which nearly half would never show up.

Without counting the approximately 100,000 people claiming to be less than age 18 who showed up last year unaccompanied by adults other than the traffickers who brought them north, it seems to me that according to current law, after 20 days the children brought by their parents this year presented three possible legal choices to immigration officials: 1) Send them back unaccompanied to the countries from which they say they had fled; 2) release them AND their parents into the U.S., pending hearings in two years, expecting that about 40% will not be seen again unless re-arrested for some subsequent offense; 3) Transfer them to appropriate facilities to be clothed, housed, fed and educated with full school curricula appropriate to their ages for a year or two until their parents’ cases made it through the immigration court.

It was this third choice, involving 2,300 minors, that has been vilified by all and sundry on the left side of the political spectrum. Yet as questions 1 through 6 imply, thousands of American kids are removed from their parents when they are incarcerated, for example, when a baby is born to a mother in prison.

In the case of the 2,300 children of most recent wave of illegal entrants into the U.S., those parents had opportunities in several locations in their countries of origin and in nine different locations during their transit of Mexico, to appear at one of the “doors” in our border (an embassy or consulate) and make application for either immigration or for sanctuary. They passed up all those legal choices, instead taking their chances by entering the U.S. illegally. From interview statements, all appear to have been aware that if they had children with them it was likely they would, under the policies of previous administrations, be released with their children and have two years to find a way to disappear into America for good.

That policy enjoyed very questionable legal foundation, however, and what the Trump officials did was simply to discontinue a policy that was a proven corrosive to our immigration process and had shown increasingly disastrous implications for our nation in terms of the absence of any time or opportunity to filter the incoming stream for criminals and undesirables before the 20-day limit when they were kicked loose with their kids into our communities.

Trump’s solution was to transfer the kids to clean and well maintained facilities with good food, safe housing and daily access to schoolrooms and classes.

The reaction to his strategy to eliminate the loophole that encouraged the use of children to force the “catch and release” option, was an immediate howl of emotion about ripping babies from the breasts of their mothers and a mischaracterization of the whole affair, completely ignoring the complicated facts and constraints never discussed in the main media.

In reflecting upon what I was writing, it put me in mind of Eric Berne’s “Games People Play”. When I was an intern and a resident I knew Berne and got to watch some of what he called Transactional Analysis (T-A) therapy groups at the McCauley Institute. His first book was published that year and naturally we all read it. Later while a family doctor, I was a co-therapist in a T-A group for four years. One of the Games Berne describes is called, “Yes, But…” In it a person asks for help in solving a problem, but their actual agenda is to prove that you can’t help them. It is a game based upon hidden rage. To win, the player has to leave you feeling frustrated and incompetent, after you have expended much time and effort to help him.

Extremists on both Left and Right in congress have been using a form of this Game, YESBUT, as their overall, long-term strategy for dealing with the conservative majority and Trump’s administration.

The dynamic of this and other Games is illuminated by the famous (Steve) Karpman Triangle, at the angles of which are the Persecutor, the Rescuer and the Victim. During the course of, and by the conclusion or PAYOFF of a Game like YESBUT, the roles have switched. The Rescuer has become the Victim or loser, and the former feigned Victim has become the winner or Persecutor. The point is not to let the Rescuer foresee that he or she is about to become the Victim.

Here’s an example of how it works.

The Con: Perceiving the weakness (gimmick) of the Rescuer, who thinks he can fix things and wants to help, the Player sets the Hook.

The Hook: “Please help us solve this immigration problem!” — but solving the problem is never the Player’s goal. It is instead to make the Rescuer (and others) feel he is worthless.

The Switch: To every reasonable and feasible idea, plan and suggestion the response is the Crossup: “YESBUT that won’t work because…(inventing some reason that is wholly in the control of the person requesting help, who has exerted no effort whatever. ) All he has to do after every effort to Help is, say ’YESBUT, that’s not it’.” Whereby he becomes the Persecutor and the Rescuer becomes the Victim.

The Payoff: The Victim, now Persecutor, says, “You are an incompetent bully an your solutions have been racist.” The Rescuer, realizing he has been tricked and is now the Victim, feels angry and stupid.

Playing YESBUT, without the slightest effort to solve any of the problems themselves, all the Left has to do is to obstruct Trump, saying, “No that’s not it”, to every solution his effort has produced. The problem Democrats (and many Republicans) have — and don’t want revealed, is that they CAN’T offer solutions of their own, because what their base truly wants is a completely open border, (they are in our streets shouting, “YOU CAN’T KEEP US OUT!”), the destruction of the sovereignty of the American people, and the sapping of the strength of the American character and economy. To make these aims explicit would infuriate about half the American people. Unfortunately for the Liberals, they are the half who own nearly all the firearms. Which, by the way, may illuminate the true reason why the Left is trying to erode the Second Amendment out of existence. Again, accomplishing by stealth and deceit that which they could never do by a frontal attack: that is via the process of amending the Constitution. 😉


46. Review: “Killing the Rising Sun”, by Bill O’Reilly

January 9, 2018

Well, Killing the Rising Sun is certainly non-fiction, and is written in the manner of a scholarly historian or investigative journalist, and while I recommend it to any who didn’t actually have a contemporary experience of World War II, and especially of the behavior of the Japanese Emperor, Prime Minister Tojo, and his Army and Navy, in their military expansion throughout Asia beginning in 1937 in China, I fear it might prove too provocative for people who are fixedly anti-war-at-all-cost, or who are determined to see America as the aggressor in every instance, even to the point of portraying the Japanese as victims.

While O’Reilly was a high school history teacher and the documentation he provides is extremely thorough, there are people who view him as a right-wing liar, and the book would be wasted on them.  Personally, I found him to be one of the commentators on Fox News that I could listen to, because while he was clearly conservative, over the years I never heard him lie about anything, and he did seem to make an effort to present or at least report opposing views. [Ed. Even in the end, he did not deny accusations of sexual harassment and left quietly.]

I think if it were me, I might poll the members of a book club to see how many were dead set against even reading his book, and make the decisions whether or not to select it for a group, based upon the result of the poll.

If one is willing to assume that what is presented — the events, facts and figures — is fair and accurate, the book does explain how it could have seemed appropriate to use the atomic bombs that ended the war in the Pacific. I know that as a boy of eleven with nine uncles in the war, it seemed the best possible outcome to me. 

One argument used by many modern academics to second-guess the decision to use atomic bombs is that the “real” reason we bombed Japan and ended the war that August was that we didn’t want Asia to fall under the control of the Soviets.  The book provides a time line that makes it clear that after Potsdam, while the Soviets did attack in Manchuria at nearly the same time as the decisions were made to use the atomic bomb, concern about Russian victory was far less an issue than were the millions of casualties anticipated from an imminent invasion of the Japanese home islands.  MacArthur, in fact, not having even been told that we had an atomic alternative, was counting on the Soviets to keep major components of the Japanese Army pinned down in Manchuria while he prosecuted an amphibious invasion that would cost an expected 500,000 American lives.

To understand how a decision could have been made to drop an atomic bomb on the Japanese cities, one has to have witnessed, or be reminded of, how the tenets of shintoism (Japan was the home of the gods and Hirohito was literally a god) and bushido had enabled or caused the Japanese to conduct themselves during their war, committing each day yet another thousand atrocities involving civilians or prisoners of war. To those who cannot understand the need to bring an immediate halt to that behavior I can only say, You had to be there.


45. Acting crazy…

January 9, 2018

When my oldest boy, now 55, was in grade and middle school among the other boys was a kid named Cary (as best I can recall), who was a little guy.

At that age the vulnerable get picked on pretty mercilessly, but nobody picked on Cary, even the school bullies. Because Cary had carefully developed the reputation for being bat-shit crazy!

Around me he seemed quite normal. Charming even, with a winning smile. But in an altercation he became out-of-control, rabid, spitting, biting, eyes-wild, hitting and kicking anything that came close enough. Kids have unwritten rules about fighting, you know. No hitting in the face, no biting, no kicking in the balls, no eye gouging. Unwritten, but still as binding as those of the Marquis of Queensbury.

Cary broke all of those rules in the first couple of fights he was in, acting as if he were literally berserk and had lost all self-control, screaming and growling like an animal. After which everyone agreed he was crazy and too dangerous to provoke.

What I and other adults saw, of course, was a kid perfectly in control of himself, about which stories we heard about this other mode of behavior made no sense.

But I figured Cary was crazy like a fox. At some younger age, I assumed, Cary, being the littlest, had struck upon this strategy to avoid incessant bullying. I couldn’t be sure he was aware it was all an act or a contrivance. He might have though of himself as just being that way: violently out of control when he became angry.

I was a family doctor in those days, and many years later when I became a psychiatrist I learned more about a condition called “intermittent explosive disorder” in children. But that is defined, (see https://en.wikipedia.org/wiki/Intermittent_explosive_disorder), as being either spontaneous or provoked by “relatively inconsequential events” and happening a couple of times a week. In other words appearing to be generated by internal storms in the limbic system, the emotional circuits in the brain.

In Cary’s case, they only happened in response to physical bullying or the threat thereof, and when he wasn’t bullied they didn’t happen for weeks, months or years at a time…or at all. So in his case I didn’t sense any lack of ability to control his outbursts, and I did perceive a specific intent and purpose.

It’s been a long time and I only heard about most of Cary’s behavior second-hand and over time, so my speculations are just that — speculations.

But I’ve always had the feeling I had seen the behavior of the Korean Dictator somewhere before, and that it represented an intentional strategy to terrorize bigger guys and was not as crazy as it looked. In a sense it is like a little guy acting nuts in order to bully bigger guys.

With previous presidents and much of the American public it has seemed to work and they responded out of fear. Both the fear of the little bully’s actions, and that he will not fight by the rules, and the even greater fear of the disapproval of the rest of the world if we were to use nuclear weapons to wipe him out.

I don’t like Trump and I think he is stupid, dangerous and unpredictable. (Oh, wait, where have I seen that strategy before!?) But I think he said what needed to be said at the U.N. if NOKO’s ambition to build a nuclear ICBM arsenal is to be thwarted. And if it is not thwarted, it will surely have to be stopped by force. And if force is used, experience tells us, it should be overwhelming force in order to maximize harm to the enemy and minimize it to ourselves.

It must amuse China to sit there on the front porch and watch their pit-bull shred our trouser legs, but the real questions is, what will China do to prevent having an American occupying army on its immediate border? Will they join the conflict in Korea as they did in 1952? Up ‘till now they’ve merely allowed NOKO to distract us from their thrust into the Spratley’s in the South China Sea, where they can later extend their territorial waters to 200 miles, and sit astride the main trade route in the Far East. ( I don’t know it that’s their plan, but it would be my plan.)

Back to NOKO’s dictator. The real question is, if we did nuke him, which bomb would be more appropriate, Fat Man, or Little Boy?

44. Unintended Consequences – 47 U.S.C. Section 230

August 17, 2017 — In a way, this is just a depressing movie review and you may want to skip it if you are in low spirits.   But it does raise a question about what congress isn’t doing while it is engaged in the endless political squabbling the world has been discussing.

[Ed. ” … In 2018, Section 230 was amended by the Stop Enabling Sex Traffickers Act (FOSTA-SESTA) to require the removal of material violating federal and state sex trafficking laws. Protections from Section 230 have come under more recent scrutiny on issues related to hate speech and ideological biases in relation to the power technology companies can hold on political discussions. “- Wikipedia  ]

For me, the greater shame we all bear for allowing ourselves to be consumed by the continuous battle of spiteful lies that American politics has become, is that we have been distracted by tricksters from the more important life-and-death issues that confront us every single day.

Last night, though I have come to avoid unpleasant entertainment, I thought I might be up to watching a documentary called, I am Jane Doe, on Netflix.  Well, I was, and I wasn’t. What unfolded in the film, described with a journalist’s reportorial style, was one of those life-and-death matters involving children, that, though known by all, has been entirely neglected by congress and the federal courts for several years.

In 1996, in an effort to restrict what it considered to be indecent speech on the internet, congress passed a law with what turned out to be the ironically Orwellian title of, the Communications Decency Act (CDA). The internet community sued, and the Supreme Court struck down those provisions which infringed free speech, leaving in place only a section —- 230 that said, “No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider” (47 U.S.C. § 230).”

Next in a tragic chain of events, a newspaper, the Village Voice, mounted an on-line classified ad section called Backpage dot com, which quickly became a major site for advertising “escort services” and ever more explicit offers of prostitution. Voice publishers were protected by the law, CDA 230, that exculpated them from responsibility for “third-party content”.

At some point more than half a dozen years ago, child sex traffickers, who had perfected the art of finding runaways or incipient runaways in their early teens, mostly 13 to 15, and of enticing them, raping them repeatedly, abusing and intimidating them and then prostituting them and commandeering their income, began to gravitate towards Backpage’s completely open advertising policy. Soon Backpage became the main marketing outlet for pimps with children to sell.

Mothers searching for their lost children began to find pictures of them in their underwear, spread-legged or downward dogging, on Backpage, with their quarter or half-hourly rates specified.

Backpage, and when it was discovered to be the owner, the Village Voice, hiding behind CDA 230, stonewalled the mothers, and some recovered children, who at first only wanted their pictures removed from the site.

Law suits against Backpage and on behalf of the trafficked children were initiated in several states over the past six years, and were struck down one after the other by federal courts on the basis that federal law, CDA 230, exculpated the publisher, the single victory occurring in the Washington State Supreme court.

When public pressure in the form of picketing and boycotts got too hot for Village Voice, it sold Backpage to a couple of “alternative newspaper” entrepreneurs from Phoenix.

Backpage’s market share in child sex trafficking grew to heavily dominate the niche and it went international. Backpage’s lawyers and spokesperson continued to maintain that they were doing everything possible to screen out the child sex ads, while their opponents in court argued that their “guidelines” merely instructed the advertisers how to use language that would not get them banned from the site. By coaching and advising the child sex traffickers in that way, opponents maintain, Backpage became a co-conspirator in the child sex trafficking industry, in the development of which they have played a major role.

As depicted in the documentary, the federal appeals courts have, sometimes with an astonishing lack of understanding of what was actually happening on Backpage despite being explicitly informed by plaintiffs, continued to maintain that it was the intent of congress to protect this “speech” with CDA 230.

Recently the U.S. Senate held hearings on the matter and subpoenaed the CEO of Backpage, who failed to show up. Arrested for contempt of congress, the federal judge again freed him citing CDA 230.

Backpage’s income is above $175 million a year and they hire the most expensive lawyers. When the Cook County Sheriff took them on directly, they sued him and won.

It seems to me as a writer and one who has read a good deal of statutory language, that by re-writing and replacing CDA 230 it would be fairly easy to clarify that the intent of congress is to protect freedom of the internet as a communications conduit, without protecting those who participate actively in child sex trafficking and are the de facto marketing arm of the industry. Why has congress not done that in the several years that this case has been widely known, and during which time the lives of thousands of children have been forever damaged or lost?

Is this just part of the general deadlock resulting from the expansion of political campaigning to fill 100% the time previously allotted to governance?

It has always been arguable that congress doesn’t actually want to solve the problems of immigration control and reform, nor of tax reform or the loss of American jobs shipped overseas to satisfy corporate greed, but in the case of child sex trafficking about which nothing has been done for nearly ten years, that conclusion, if mysterious, is inescapable. This inactivity of congress may partly be explained by the fact that special interest groups pay “our” representatives more money in fungible “campaign contributions” than we do in salaries.

Even if one does not object to prostitution as a cottage industry, nor even adult pornography, what we are talking about is the literal, actual slavery of children, and further abuse of the worst possible kind during that enslavement.

I don’t think I ever before this moment, and I had three years of high school Latin, fully understood the implication of, “Nero fiddled while Rome burned.”

43. A Story for the Fourth of July 2017

July 1, 2017

Back to School


Late this spring I caught wind of an on-line summer course being offered to alumni of the University of Chicago. Tied to the current high general interest in the subject of charges and countercharges of “fake news” in the overheated political aftermath of the Trump election, the six-week course was named, Truth and Language”.

It drew my immediate attention as a retired forensic psychiatrist with a particular interest in characterologic disorders, and especially the Cluster B Personality Disorders: Borderline, Narcissistic, Histrionic and Antisocial. It is fair to say that these disorders and traits correlate highly with the characteristics and behavior of politicians.

However, taught by a well respected professor of linguistics, the course, with 110 enrollees, began with and tended to remain focused upon the philosophical and semantic analyses of truth from the point of view of symbolic logic and truth tables. Our early readings were about sentences structure, truth-testing and meanings. There was an ongoing discussion of Aristotle’s Principle of Non-Contradiction: That the same statement cannot be both true and not true at the same time. We only arrived towards the end at Harry Frankfurt’s essay and theory of, “Bullshit”, and a look at the characteristics, as seen by Frankfurt and Cohen, of a bullshitter as opposed to a liar.

In summary, for the most part the focus remained generally upon truth, and whether it was an objective thing at all, or was instead changing and relative.

I, on the other hand, was equally as interested in the value of lying, which I think may be more prevalent than truth-telling. From lengthy discussions among the dozen or so active participants, many experts in their own fields, eventually I drew these conclusions:

Telling the truth is by and large safe and advantageous when the communicating parties are engaged in a cooperative venture, such as as when the Congress is governing the country, or when scientists investigate the mysteries of the universe.

Telling the truth is risky and lying is safer and more advantageous when the communicating parties are in competition with one another, ranging from the most benign sort of entertaining competitions clear up to global war.

From the foregoing I extrapolated that governance can only be done cooperatively or by brute force. Campaigning for office is always a competition and can range from the ethical and friendly to the most desperately vicious.

I seems to me that as a general rule, cooperation and competition are fundamentally incompatible and cannot coexist in the same time and space and between the same groups or individuals.

We are in our present pickle and buffeted by a tempest of lies because, in a violation of the essential agreement that in a democracy the majority rules, the losers in the last election have refused to concede that according to the rules under which the election was held, Trump was the winner. I can certainly empathize with their fear and outrage but I do think that their refusal to accept the election results has triggered the current problem.

Consequently, due to both of the competitors fiddling with the rules, and because the Jerry Springerized media have decided that the most attractive way to fill the 24 hour a day vacuum of the cable news schedule is with fighting, presidential and other campaigns have in this way now explosively expanded to fill all of the time between elections.

However, while the lying and fighting are now continuous, things have not quite escalated to resorting to brute force. Hence — governance has been excluded from the activities currently possible.

My solution, perhaps simplistic, would be to limit campaigning to the three weeks prior to the election. And to limit campaign contributions to, say, $500 per human citizen, no exceptions, no fiddles, no fudging, no bundling, no coercion, on pain of a very severe penalty. Those who are inclined to get back to work solving real problems would no longer be prevented from doing so by those who are not.

A Story About the Flag

In the days when the course on Truth was winding down the AlumniU website announced that another course was in progress. This one, called Connecting the Curious: Sex and the Constitution, was being taught by a famed constitutional scholar and former dean of the Law School. It was based upon his book about sex, religion and the law throughout the life of the nation. I immediately jumped into the course, catching up on reading the Brandeis opinion in Whitney v. California; Brennan’s decision in Frontiero v. Richardson; Warren’s decision in Brown v. Board of Education; Marshall’s dissent in San Antonio School District v. Rodriguez; and of course, Harry Blackmun’s encyclopedic decision in Roe v. Wade.

I watched the short videos submitted by Professor Stone, and too ignorant to be cautiously humble, leapt into the on-line discussion in progress. I was very impressed by the level of the materials and discussion and feel that my efforts were richly rewarded.

Because of a vague reluctance I did not explore, I neglected one video entitled, “Goef Stone Defaces a Flag”. Until the course was over and I was merely cleaning up loose ends.

In the two or three minute video, clipped without context from a speech before an appreciative audience, the Professor recounts a time when he and his then wife attended a march in front of the White House of ‘hundreds of thousands” of people wearing triangular pink pins.

[Ed. It seems the pins had been adopted as an emblem of gay pride and that the march was in support of gay marriage.]

The Stones were actually in Washington to attend a reunion of Justice Brennan’s law clerks, of which he had famously been one. He describes that they were in the supreme court where there is an American flag adjacent to the dais on which the justices sit. Careful to be unobserved, they pinned a pink triangle to one of the red stripes on the flag. He said, with a smile, and to chuckles from the audience, that as far as he knew, it was there still.

A classmate had commented with good humor, that he was glad to see that despite the adoption of a coat and tie in recent years, the activist in shirtsleeves and jeans still resided within.

Though the course has been over for more than a week, after thinking it over I added this comment, which I am not sure anyone will see:

Since the Flag Desecration Amendment failed to pass by one senatorial vote, and defacing the flag has been protected speech (articulated in Tex. v Johnson, 1989). it appears to me that the act was not illegal.   From the video clip it is not clear to me when the flag was “pinned”.  Nor, even if it had been an offense at the time, whether the statute of limitations would have run.

I was not aware of the significance of the pink triangle and had to look it up.

As one who grew up during World War II, and who has served in the Army in Germany when Khrushchev had threatened to overrun us if we were not out of Berlin within six months;   as one whose ancestors have served the nation and its flag, back to 152 years before the Revolution; and whose son survived a year-long tour in Iraq flying the wounded from roadside IED crater to “Baghdad E.R.”,   I can’t think of a cause so important to me that I would disrespect the flag rather than find some other way to express my support for it.  No more than I would disrespect homosexual behavior or relationships between consenting adults.

Personally I had some reservations about homosexual marriage, thinking that some benefits may have accrued to the institution over the centuries that had developed for the support of parents raising kids, and might not be as appropriate for two-breadwinner, childless families.  But having never subsequently actually run across examples that reified that concern, my reservations eventually faded.  I had always been quite willing to see some sort of civil union used, but now I don’t really mind if the title of marriage is used.  I guess as the breadwinning father of four, and later a single dad with four kids, I had felt a little jealous about the title I had earned in what I thought of as, the hard way. 

I am not at all a religious person and have never had moral objection to sexual expression between consenting adults that is benevolent and loving.

But though it was quick, clever and impulsive — cute even — the flag story only made me sad.  As if it had more to do with “street creds” for a liberal academic — was more like a thoughtless college prank than a brave symbolic act.

I don’t wish to be sanctimonious or maudlin.  I don’t mean for this to be a criticism or dismissal of other great work, or to be disrespectful to Professor Stone.  I realize that there may have been more to the story, to the act, not revealed by the brief video clip.  Nevertheless, I thought that rather than let the story stand unremarked, I ought to explain how it made me feel, and why.   

SCOTUS and Psychotherapy

In my view, the choice of whose definition applies often turns on whose purposes are to be served.

In citizens United v. Federal Election Commission SCOTUS ruled that laws that prevented corporations and unions from using their general treasury funds for political advertising violated the First Amendment protections of free speech.

In Texas v. Johnson, SCOTUS invalidated prohibitions on desecration of the American Flag on the same basis, that it is protected speech.

Both decisions extend the protections of the First Amendment deep into territory that I, as a mental health professional, would call “behavior” rather than speech. Moreover, the first one extended the protection to the fictitious entity of a corporation and the organizational structure of a union political action committee.

Though psychiatry is increasingly relegated to treatment of patients with psychoactive drugs, either enhancing or suppressing the effect of some of the body’s neurotransmitters, psychotherapy has stuck to “talk therapy”, though that too is structured in new and different ways, thought or demonstrated to be more effective than older versions. Still, one of the guiding principles is to help patients change dysfunctional behaviors by examining and expressing impulses and feelings with language rather than acting them out.

Thus, for instance, a therapist might simply stop therapy for the day if a patient insists upon acting out his or her rage with raised voice, rough language and intimidating approaches or flailing of arms. The message being, “I will listen to your words, but I will not remain when your behavior becomes intimidating, bullying, frightening or dangerous.” In short, that “I will listen to you and help if I can, but I will not fight with you or allow myself to be abused.”

(I have thought of late that the President’s Press Secretary could take a page from that playbook, responding to actual questions, and stopping the individual questioner or the entire briefing when attacked verbally or in a bullying way, simply declining to engage in that way with adversarial reporters.)

So from that point of view speech is verbal, and conducted in a basically respectful way. Burning a flag, or a car or breaking store windows is not speech it is rioting, it is unsafe, and can be prohibited. Somewhere between the two there is a reasonable boundary. Writing something on my own American flag may be offensive to many, but is permissible. Defacing someone else’s flag, or one belonging to a government may not be.

Though acts against the flag may violate other laws SCOTUS has said the desecration itself may not be prosecuted as a separate crime. Well, at least that is as I, not a lawyer, see it.

I think I may not have managed to clarify the issues, and in fact may have further complicated them with my talk about psychological factors. However, I can recommend the Wikipedia entry on Texas v. Johnson at https://en.wikipedia.org/wiki/Texas_v._Johnson, which does an excellent job.

The Professor’s story about defacing the American flag may have hurt my feelings, as it was at least in part intended to do, but hurting my feelings is not against the law.


42. The Iatrogenic Opioid Epidemic

April 29, 2017

For forty years I have been adamantly against the over-prescription of opioid pain medications: typically Percodan or Percocet. The generic name for the main ingredient of those medications is oxycodone. See: https://en.wikipedia.org/wiki/Oxycodone

With the rise of “pain clinics” in the 1990’s, physicians who believed, or pretended to believe, the myth heavily promoted by drug companies that opioids, when given for actual pain, would not addict the recipient, convinced the medical licensing boards in California and elsewhere that doctors as a rule were shamefully “under-treating” chronic pain patients. Acting upon that false narrative, those boards, in turn, chastised doctors for this purported “under-treatment”, and forced them to take special courses as part of their Continuing Education requirement, encouraging them to prescribe opioids for any claimed chronic pain, whether the source of the pain was or was not able to be demonstrated: whether the pain itself made any rational sense or had a medical explanation.

This movement, I believed then and I believe now, was closely allied with the politically liberal “legalize pot”, (“legalize everything”) permissive agenda. I, on the other hand, having believed my 1962 medical school pharmacology teachers on the topic of opioids, benzodiazepines and other addicting substances, and after enduring the frustration of trying to wean a couple of patients off Percodan originally prescribed by other practitioners, never again prescribed Percodan to any but hospitalized patients with very severe, acute pain. And never prescribed even codeine for more than two or three days.

That was my policy, but since I, as a family doctor, never actually had sole hospital responsibility for a patient with fracture or post-operative pain, such patients usually being under the care of the orthopedist or surgeon on the case, in practical terms it meant that I never again prescribed oxycodone in any form. To any patient coming to me demanding opiates, I offered to help them get off addicting drugs and on to non-addicting analgesic medications and physical modalities to reduce pain. None ever took me up on my offer.

Recently a friend, citing physician income figures alone, attempted to make the case that physicians generally were significantly motivated by money. I disagreed, citing the much lower ‘dollars per hour of work’ figure and the many other rewards for altruism. But to the extent that there are physicians who are essentially in it for the money, I have always suspected the “pain management” crowd, and those doctors who make a living prescribing methadone, buprenorphine and other opioids to heroin addicts in the name of what is called a “harm-reduction” strategy. Their theory being that it is better for addicts to take a legally prescribed oral narcotic paid for by the state than to rely upon street drugs injected with dirty needles.

As one often involved in group interventions and referral of alcoholics to 28-day treatment programs, in a specific practice setting that yielded a 96% recovery rate, I have always questioned the fact that “addiction maintenance” practices are not associated with programs or efforts to actually detox the patient and get him or her beyond the phase of actual addiction to the substance in question. It has always seemed to me that such “maintenance” programs were examples of what is called “enabling” behavior and benefitted mostly the prescribing doctors. Some might find that a harsh position, but as a recovering alcoholic and nicotine addict with 40-plus years of abstinence from both substances, I am quite convinced that actual recovery is possible, and that for a physician to give up on that option and switch to a maintenance or “harm reduction” strategy is disturbingly self-serving. If some doctors are that pessimistic about treating addictions themselves, if it is not for the money, why not practice some other branch of medicine? Then again people in the helping professions are often from backgrounds that breed codependency. So there’s that possibility.

Today we are living with the consequences of the ill-advised public health policy adopted by state medical licensing boards. The huge upswing in overdose deaths from prescriptions painkillers became undeniable, and medical licensing boards are now participating in the swing of the pendulum in the opposite direction. I predict that despite our best efforts, it will take twenty years to undo the harm that the “harm-reduction” ideology has wrought.

The following excerpt is from the newsletter of Arizona Senator John McCain and represents movement in the right direction.

As the dangerous opioid epidemic continues to grow and devastate communities across the country, it has never been more important to advance solutions that will stop the scourge of these addictive drugs at the root. One of the main causes for the alarming increase in drug overdoses in the U.S. is the over-prescription of highly addictive opioids, which have increased by 300 percent over the last 15 years. In fact, people who are addicted to prescription opioids are 40 times more likely to become addicted to heroin.

We need to stop addiction before it’s too late. That’s why I joined Senator Kirsten Gillibrand (D-NY) this month to introduce legislation that would combat opioid addiction and abuse by limiting the initial supply of opioid prescription for acute pain to seven days. Opioid addiction and abuse is commonly happening to those being treated for acute pain, such as a broken bone or wisdom tooth extraction effecting individuals as young as teens. This legislation is modeled after laws in several states, including Arizona and New York, and it builds off Governor Doug Ducey’s work last fall that directly tackles the root cause of over-prescription.

Veterans, many who continue to carry the wounds of war, are especially susceptible to over-medication of addictive opioids, which can often lead to suicide. Since 2001, the rate of veteran suicide has increased by 32 percent. After controlling for age and gender, this makes the risk of suicide 21 percent higher for veterans than the average U.S. adult. Since 2001, there has been a 259 percent increase in narcotics prescriptions. In the largest veteran populations, veterans die from accidental narcotic overdose at a 33 percent higher rate than the rest of the population.

I recently introduced the Veterans Overmedication Prevention Act to combat this problem by directing the VA to conduct an independent expert study on the deaths of all veterans being treated at the VA who died by suicide or drug overdose in the last five years. This review would ensure that the VA has accurate information about the relationship between veteran suicides and prescription medication.

Stopping the over-prescription of addictive opioids is critical to putting an end to this tragic epidemic. These pieces of legislation build on important efforts to end the tragedy that continues to claim far too many lives far too soon.